Neurophysiology - University of Toledo · How to organize Neurophysiology. ... anisocoria •...

Neurophysiology

Making The Connections

Embryology of the Brain

In the first trimester…• Notochord visible by three weeks• Brain fully formed by 8 weeks• Brain is active early with movements,

especially reflexes• Swallowing is an intrauterine reflex• Brain is active in formation of amniotic fluid

Amniotic Fluid• 80% is a filtrate of mom’s plasma

– Fetus SUBTRACTS by swallowing the fluid,– Fetus must absorb and digest the fluid

• 20% is added by the fetus– Fetus then urinates the additional fluid into the

sac

Polyhydramnios• Neuromuscular disease

– Autonomic dysfunction– Muscle disease

• GI obstruction

Oligohydramnios• Renal agenesis • Urinary outlet obstruction

• Potter’s syndrome

Spinal Cord• Develops from the notochord• Goes down as far as L-1 or L-2• Ends as the Conus Medullaris

• Nerves come off to the sides as the cauda equina

• Filum terminalis: anchors the tip of the conus medullaris to base of the spinal canal

Vertebral Arches• Fuse ventral to dorsal• Fusion begins at the cervical level and

proceeds bidirectionally• If child born prematurely, a hole can be

still present at either end

Upper vertebral arch defects

• Anencephaly• Encephalocele• Encephalomeningocele• encephalomeningomyelocele

Lower vertebral arch defects• Spina Bifida Occulta• Spina Bifida Aperta• Meningocele• Meningomyelocele

– Arnold Chiari Malformation– Syringomyelia

Now you need some CSF

CSF• A filtrate of plasma• Made by the Choroid Plexus in each

ventricle• Requires vitamin A• Requires carbonic anhydrase

How CSF differs from plasma• Less HCO3• More CL• Lower pH 7.34• Up to 25 WBCs normal in first month of life

only; after that, only up to 3 WBCs normal

CSF Flow• Lateral ventricles > foramen of Munro > 3rd

ventricle > aqueduct of Sylvius > 4th

ventricle > foramina of Lushka and Magendie > subarachnoid layer > spinal canal > dural sinuses > back into plasma

Vomiting Centers• Chemotactic Trigger Zone: located on the

floor of the 4th ventricle– Responds to any increase in ICP– Uses dopamine

• Area Postrema: located on the blood side of blood:brain barrier– Responds to offensive smells or particles– Uses dopamine

Hydrocephalus • Noncommunicating: due to an obstruction• Communicating: overproduction of CSF

• Applies pressure on the brain

Communicating Hydrocephalus

• Newborns: mainly in premature newborns– Intraventricular hemorrhage

• Children: due to inflammation– meningitis

• Adults: overingestion of vitamin A– Pseudotumor Cerebri

• Elderly: due to brain atrophy– Normal Pressure Hydrocephalus

Normal Pressure Hydrocephalus ( NPH)

• ventricles expands as the brain atrophies• Enlarged ventricles then compress the

long midline fibers that go to the bladder and legs

• Dementia• Incontinence• ataxia

To treat NPH…

PLACE A VP SHUNT

Noncommunicating Hydrocephalus

• Due to some form of obstruction• In newborns

– Aqueductal stenosis– Dandy-Walker cyst

• In children: meningitis, especially TB• In adults: cancer• In elderly: cancer

The role of CSF• To add cushion for the brain• Shock absorption

• Head Injury– Coup lesions– Contracoup lesions

Embryology of the brain

How to organize Neurophysiology

Visual Cortex• Remember that everything is REVERSED• Temporal fibers see the nasal visual field• Nasal fibers see the temporal visual field• Light must hit the retina by 3 months of

age or the child is blind for life• You must verify that a child has a RED

reflex on eye exam at birth

Abnormalities of the Eyes• Anisocoria: unequal pupil size• Amblyopia: difference in visual acuity• Strabismus: misalignment of the eyes• Stigmatism: corneal defect• Myopia: nearsightedness• Hyperopia: farsightedness• Presbyopia: loss of accomodation seen

with aging

Visual field deficits

White Reflex• Cataracts: opacification of the lens

– Does not allow light to hit the retina– Must be removed– Increased incidence with high glucose or

galactose ( sorbitol or galactitol accumulates)

– Idiopathic: 90%– Diabetes or galactosemia– Rubella

White Reflex• Retinoblastoma (rare)

– Rb gene– Cancer – High association with Ewing’s sarcoma

Monocular blindness• Newborns: cataracts or retinoblastoma• Children: optic nerve gliomas

– Neurofibromatosis– MEN III

• Adults: embolic phenomena– TIA– Acute retinal artery occlusion– Acute retinal vein occlusion

• Elderly: macular degeneration

Optic Chiasm Lesions• Loss of nasal fibers bilaterally• Bitemporal hemianopsia

• Pituitary tumors: 90%– Pituitary sits just beneath the chiasm

• Pineal tumors– Pineal gland sits just lateral to the chiasm

Visual field deficits

Optic Tract Lesions• Lesion of IPSILATERAL temporal fibers

and CONTRALATERAL nasal fibers• Homonymous Hemianopsia

• Mcc: cancers and tumors

Visual field deficits

Quadranopsia• Only way to get such a lesion is back in

the calcerine fissure• Pie in the sky deficit• Make sure you reverse BOTH words

What unique information does each cortex contain?

Frontal Lobe ( Precentral Gyri)

• CST ( motor fibers) originates from here• Unique information:

– Personality– Abstract reasoning

Frontal Lobe Lesions• Atonic seizures• Dimentias

– Alzhiemer’s– Pick’s disease

• Schizophrenia: loss of asymmetry• Frontal lobotomies

Temporal Lobe• Hearing• Balance • Hallucinations ( controlled by serotonin)

• Posterior temporal lobe: Wernicke’s area

Temporal Lobe Lesions• Temporal lobe seizures• Schizophrenia• Dementias • Drugs

– SSRI– Amphetamines

Amphetamines• Taken up presynaptically; cause release of

catecholamines• Clue: vertical nystagmus

Amphetamines• Used in ADD

– Methylphenidate– Pemoline– Adderal– dexadrine

• OTC for weight loss– dexatrim

• Cause hallucinations– LSD– PCP– ECSTACY

SSRI’s• Fluoxetine• Paroxetine• Luvoxetine• Sertraline• Nefazadone• Trazadone

Parietal Lobes• Dominant lobe: long term memory; all the

things you learned since kindergarten– left side is dominant in 90% of right-handed

and left-handed people• Nondominant lobe: apraxia and

hemineglect– Right side is nondominant in 90% of right-

handed and left-handed people

THALAMI• Epithalamus• Thalamus• Hypothalamus• Subthalamic Nucleus

Epithalamus• The ONLY nucleus with NO known

function

Thalamus• ALL SENSORY information in and out of

the brain MUST stop here• ALL information about the ARMS stay

LATERAL• ALL information about the LEGS stay

MEDIAL

Thalamic Infarct• ALL sensory information from the body is

lost, but motor information is intact

Hypothalamus• Controls hunger

– Hunger center: lateral– Satiety center: medial

• Controls menstrual cycle• Controls temperature

– Anterior: cools– Posterior: warms

• Controls stress response

Stress Response• Parasympathetic discharge always first• Sympathetic discharge always second

• Stress ulcers• Curling’s ulcers• Cushing’s ulcers• IBS

Acetomenophen• Works at the level of the hypothalamus• First, it cools the body ( stimulates anterior

hypothalamus) then it resists fever (blocks posterior hypothalamus)

• Oxidizes the liver (toxicity)– Treat with n-acetylcystiene ( reducing agent);

the four hour level is the most important factor

Subthalamic Nucleus• Final relay station for coordinating fine

motor movements• Lesion: Ballismus and Hemiballismus

Internal Capsule

Substantia Nigra• Responsible for INITIATING movements• Uses DOPAMINE for neurotransmitter• Receives inhibitory signals from basal

ganglia via ACH or GABA

Parkinson’s Disease• Loss of DOPAMINE fibers from substantia nigra

to striatum (caudate and putamen)• Unable to initiate activities

• Mask like facies• Bradykinesia• Shuffling gait• Fenestrating gait• Pill rolling tremor• Autonomic dysfunction: Shy Dragger syndrome

Parkinson’s Disease, cont• Treatment: L-dopa/ carbidopa

– Bromocryptine– Amantadine– selegyline

Movement disorder in middle-aged people

• Huntington’s disease– 90%– Autosomal dominant– Trinucleotide repeats– Caudate nucleus

involved– Anticipation– Decreased GABA

fibers– Treat with DA blockers

• Wilson’s disease– < 10%– Autosomal recessive– Ceruloplasmin def– Copper excess– Lenticular nucleus

involved– Kayser-Fleischer rings– Liver involvement– Treat with

penicillamine

Internal Capsule• ALL MOTOR fibers going in and out of the

brain goes through here• Blood supply comes from the

lenticulostriate arteries ( smallest arteries in the brain)

• Lacunar hemorrhages: due to HTN– Causes significant MOTOR deficits

Reticular Activating System (RAS)

• Maintain FOCUS on one item at a time• Requires NE and Serotonin• C-AMP second messenger• Has a refractory period first thing in the

morning

Attention Deficit Disorder• ADD or ADHD• RAS not working• Poor attention and focus• Restlessness• Unable to sit long enough to complete a

task• Tx: methylphenidate; pemoline; dexadrine;

adderal

Internal Capsule

Midbrain

Corticospinal Tract• Responsible for fine motor activity• Has to inhibit extension so that smooth

flexion can occur

• Spasticity• Babinski• Hyperreflexia• Clonus

Corticospinal Tract, cont• Fibers originate from the frontal lobes, the

precentral gyri• Fibers descend through the internal

capsule and CROSS at the medullary pyramids

CST Pathology• Atonic seizures: depolarization goes

across the frontal cortex• B-12 deficiency• ALS

Midbrain

Increased Intracranial Pressure

• First sign: papilledema• First symptom: headache

• Second sign: esotropia (CN VI paralysis)• Second symptom: diplopia or blurred

vision

Increased Intracranial Pressure

• First sign of herniation: (CN III paralysis) loss of pupillary reflex; anisocoria

• Herniation is down to level just above the red nucleus

• CST and Corticorubral pathways are both compressed

Midbrain

If Herniation Continues…• Second sign of herniation:

DECORTICATE posturing• Compression has ocurred to below CN III

but above the red nucleus• Red nucleus still makes the upper

extremities flex while the legs extend• UNTIL…

The Final Push• Herniation goes beyond the red nucleus• CST and Corticorubral and rubrospinal

tracts are all lost• All extremities will extend by default• Medulla is pushed through the foramen

magnum.

• DECEREBRATE posturing

Midbrain

Dorsal Columns• Vibratory sensation• Two-point discrimination• Position sense• Conscious proprioception• The only sensory pathway with four

synapses

Dorsal Columns, cont• Fasciculus: made up of a few fibers• Tractus: more fibers than a fasciculus

• Gracilis: carries leg fibers; located MEDIALLY

• Cuneatus: carries arm fibers; located laterally

Dorsal Columns, cont• FIRST SYNAPSE: dorsal root ganglion• Forms fasciculus gracilis, then tractus

gracilis ( lower extremities)• Forms fasciculus cuneatus, then tractus

cuneatus ( upper extremities)• SECOND SYNAPSE: nucleus gracilis and

nucleus cuneatus in MEDULLA

Dorsal Columns, cont• THIRD SYNAPSE: THALAMUS• FOURTH SYNAPSE: parietal lobes

( postcentral gyri)

Dorsal Column Pathology• Syphilis• Vitamin B-12 Def• Brown-Sequard

Spinothalamic Tract• Pain and Temperature• The only pathway that CROSSES in the

spinal cord• Fibers enter the spinal cord, ascend two

levels, then cross to opposite side via the anterior white commissure

Spinothalamic Tract• FIRST SYNAPSE: dorsal root ganglion• SECOND SYNAPSE: thalamus• THIRD SYNAPSE: parietal lobes

( postcentral gyri)

Spinothalamic Tract Pathology

• Syringomyelia

Spinocerebellar Pathway• The only pathway in the spinal cord that

crosses twice ( equivalent to ipsilateral)• Responsible for depth perception• Signs of damage:

– INTENTION TREMOR– DYSMETRIA or PRONATOR DRIFT– DYSDIODOKINESIS– ROMBERG SIGN

Spinocerebellar Pathway, cont

• This pathway does NOT reach the cortex• Unconscious proprioception• FIRST SYNAPSE: dorsal root ganglion• SECOND SYNAPSE: thalamus• THIRD SYNAPSE: cerebellum

Spinocerebellar Pathway Pathology

• Alcohol attacks the vermis (midline) of the cerebellum while other diseases attack the hemispheres

• Fredrieck’s Ataxia• Ataxia Telangiectasia• adrenoleukodystrophy

PONS• Responsible for responding to the

environment • Contains the PNEUMOTACTIC and

APNEUSTIC center• CNS area most sensitive to osmotic shifts

Pons – Pathology• Locked-in Syndrome• Central Pontine Demyelinolysis

Medulla• Controls ALL basic functions

Make sure you know the cranial nerves !

How Do I Figure Out Any Lesion?

You know it’s a spinal cord lesion when…

• Pain and temperature loss is opposite to all other deficits

• Level of the lesion is two dermatomes above where pain and temperature loss begins and on the opposite side

You know it’s a CNS lesion when…

• UMN signs on one side of the body ( upper and lower extremities)

• The lesion is on the opposite side of the brain

• Use the cranial nerves to locate the level of the lesion

The most important organ!!!

• The Brain

•The End The End The End